Medical practitioners see multiple patients daily for a wide variety of problems. Traditionally, records have been kept on paper. Practitioners create records for each patient, or “member” or “client.” In smaller offices, records often are kept by hand. Records are filed on a shelf or in a file cabinet and subject to loss or misfiling. Notes concerning office visits, or “encounters” (defined below in the Detailed Description section), may be disorderly within member files. Practitioners reviewing such records while preparing to meet a patient are often pressed for time. Reviewing such records thoroughly on short notice is difficult often leading to cursory reviews and poor follow-up on symptoms. Often, only the very recent past is thoroughly reviewed. There is nothing in the typical system to prompt a practitioner faced with a particular symptom or condition to look for related problems. The practitioner's records often do not contain information on pharmaceuticals and courses of therapy or treatments used by an individual member, particularly if the service was rendered outside the practitioner's office or by another practitioner.
At the conclusion of an encounter, the practitioner typically handwrites or dictates notes concerning the visit and the notes are filed in the member's file. In either case, retrieving the information is done by opening paper files and reading the paper records. This method of recordkeeping is more apt to happen in private practitioners' offices than in hospital settings.
Billing is typically accomplished using what's known as a “Superbill.” The Superbill contains a list of possible conditions. The practitioner enters the member's name on the Superbill and proceeds to check off any conditions for which the member was seen. If the practitioner forgets to ask about a related condition during the encounter, that condition cannot be billed. Only conditions actually addressed during the encounter can be placed on the Superbill and submitted for payment.
The present invention is intended to supplement the practitioner's current system by providing a simple, time saving solution to a number of the problems inherent in those systems. The present invention collects and stores practitioner and member data in a remotely located or less often a local secure database. Accessing the database, the practitioner prepares an encounter form to be used during each member visit. The encounter form displays the member's medical history including recent complaints, conditions, medications, tests, and referrals. It also highlights additional conditions that are commonly associated with or related to the member's recent conditions. Thus the system prompts the practitioner to inquire about commonly related subjects ensuring that such items do not go unnoticed and untreated.
The pre-encounter form takes about 15 seconds to produce and saves the practitioner valuable time that otherwise would be spent reviewing manually produced records and prepares the practitioner for the member visit. The pre-encounter form is usually printed for use during the visit, but it can be completed on-line during the visit, and ordinarily can be opened, viewed, and completed from within other existing medical recordkeeping software programs—Electronic Health Records (“EHR”) or Electronic Medical Records (“EMR”).
During a member's visit, or encounter, the practitioner, places a check mark next to each pre-printed condition addressed during the visit. The highlighted conditions serve to remind the practitioner of previously addressed complaints and those commonly related conditions that should be addressed. The practitioner also notes the primary reason for the visit, and signs and enters the date on the form.
After the office visit, the pre-encounter form is used as an aid in making the post-encounter entries on the appropriate form using the inventive software. Post-encounter entries can be made by the practitioner or by office staff. To make the entries, the user opens the post encounter form on a computer terminal and then fills-in the indicated information according to on-screen instructions. The information collected includes all conditions addressed during the visit, and any medications or follow-up treatments or referrals ordered as a result of the visit. The software stores all of the visit data in the secure server making the data available for future visits. After the post encounter entries are completed, the encounter form is used to ensure billing is accurate for the conditions addressed. Data gathered on many patients is used to determine which patients are worthy of enhanced attention.
Practitioners would normally complete and save their traditional documentation in the usual manner according to their normal office procedures.